A nurse is reinforcing teaching with new parents about the provider's prescription for a serum bilirubin test. Which of the following statements should the nurse include in the explanation?

A. Hypertension: Clients experiencing diabetic ketoacidosis (DKA) are more likely to present with hypotension rather than hypertension due to dehydration caused by osmotic diuresis. Volume depletion significantly lowers blood pressure rather than raising it in the setting of DKA.

B. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of DKA. It results from the accumulation of ketones, particularly acetone, in the blood, which the body attempts to eliminate through the lungs, giving the breath its characteristic sweet or fruity smell.

C. Protruding eyeballs: Protruding eyeballs, or exophthalmos, are associated with hyperthyroidism, particularly Graves' disease, not with diabetic ketoacidosis. DKA affects metabolic and acid-base balance but does not cause changes to eye appearance or positioning.

D. Decreased urinary output: In the early stages of DKA, clients usually experience increased urinary output (polyuria) due to osmotic diuresis from hyperglycemia. Decreased output may occur only in the later stages when severe dehydration and kidney compromise develop, but it is not an early expected finding.

• Weight: The client has gained over 1 kg (about 2.2 lb) within a week, suggesting fluid retention. In combination with crackles, edema, and cardiomegaly, this weight gain indicates worsening heart failure and requires prompt intervention to manage fluid overload.
• Potassium: A potassium level of 3.5 mEq/L is at the lower limit of normal. While it should be monitored, it does not independently demand immediate action unless it trends lower or the client shows symptoms of hypokalemia.
• Pedal pulses: Pedal pulses have decreased from 2+ to 1+, and the extremities are now cool. These changes suggest compromised peripheral circulation, likely related to decreased cardiac output, and warrant further assessment and management.
• Temperature: The client’s temperature is within the normal range. There are no signs of fever or hypothermia, so this finding does not require immediate action based on the current clinical data.
• Orientation: The client remains alert and oriented, with no noted decline in mental status. Therefore, orientation findings are stable and do not necessitate further immediate intervention.
• Chest x-ray: The presence of cardiomegaly on chest x-ray suggests worsening heart failure or fluid overload. This finding is significant and requires timely medical evaluation and management to prevent further cardiac decompensation.
• Urine output: The client’s urine output has drastically decreased from 520 mL/hr to 160 mL in 8 hours, indicating impaired renal perfusion or acute kidney injury. This is a critical finding and requires immediate provider notification and intervention.